8 Pop Quiz Select the most correct answer NTSB has statutory authority to investigate aircraft accidents involving the following types of aircraft: a. aircraft operated under Part 91 and 121 b. military aircraft c. civil aircraft d. all of the above e. none of the above

9 Pop Quiz Select the most correct answer NTSB has statutory authority to investigate aircraft accidents involving the following types of aircraft: a. aircraft operated under Part 91 and 121 b. military aircraft c. civil aircraft d. all of the above e. none of the above

10 49 USC 1132 (a) GENERAL AUTHORITY. (1) The NTSB shall investigate: (A) each accident involving civil aircraft; and (B) with the participation of appropriate military authorities, each accident involving both military and civil aircraft.

35 DPS Cabinet Secretary Had formerly been a NMSP chief pilot Liked to be involved with aviation section, but did not ensure it had an effective safety program Wrote memo saying that accident pilot was authorized to operate the accident helicopter Took actions that were detrimental to safety Dismissed former chief pilot for turning down missions Demanded explanations whenever a pilot declined a flight Complained vigorously when New Mexico National Guard pilots launched when NMSP declined Would ask NMSP pilots to continue checking the weather when they had already declined mission due to weather

36 NTSB Finding there was evidence of management actions that emphasized accepting all missions, without adequate regard for conditions, which was not consistent with a safety-focused organizational safety culture...

37 Probable Cause: The pilot s decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions. Contributing to the accident was an organizational culture that prioritized mission execution over aviation safety, and the pilot s fatigue, self-induced pressure to conduct the flight, and situational stress.

41 NTSB Finding The Alaska Department of Public Safety lacked organizational policies and procedures to ensure that operational risk was appropriately managed

42 NTSB Finding The Alaska Department of Public Safety s reliance on nonaviation-trained dispatchers for dispatch and flight-following support does not ensure that flight crews have adequate access to up-to-date weather information and qualified assistance with flight risk assessment tasks..

43 NTSB Finding The Alaska Department of Public Safety did not provide the pilot with training that could have helped him recognize the hazards that precipitation and low light conditions pose to night vision goggles operations.

44 Probable Cause The pilot s decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot s spatial disorientation and loss of control. Also causal was the Alaska Department of Public Safety s punitive culture and inadequate safety management, which prevented the organization from identifying and correcting latent deficiencies in risk management and pilot training. Contributing to the accident was the pilot s exceptionally high motivation to complete search and rescue missions, which increased his risk tolerance and adversely affected his decision-making.

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